Cedar Care Assisted Living Home

Based upon record review, documentation review, and interview, the manager failed to ensure that medication administration was documented by the individual administering the medication at the time it was administered, for two of two residents sampled. The deficient practice posed a risk if the residents did not receive medications due to documentation errors, and the Department was provided false and misleading information. Findings include: 1. Record review established that R1's medication administration record was marked as Trazodone 50mg administered at 8pm on September 24, 2024. However, the compliance inspection occurred on the morning of September 24, 2024. The Trazodone 50mg was not documented by the individual administering the medication at the time it was administered. 2. Record review established that R2's medication administration record was marked as Mirtazapine 7.5mg administered at 8pm on September 24, 2024. However, the compliance inspection occurred on the morning of September 24, 2024. The Mirtazapine 7.5mg was not documented by the individual administering the medication at the time it was administered. 3. Documentation review established a section of the facility's policies and procedures titled "Medication Services". Within this subsection was the instruction that all medications would be "Administered and documented in compliance with a medication order". 4. In an interview, E1 confirmed that R1's medication administration record was marked as Trazodone 50mg administered at 8pm on September 24, 2024, and that R2's medication administration record was marked as Mirtazapine 7.5mg administered at 8pm on September 24, 2024. However, the compliance inspection occurred on the morning of September 24, 2024.

Based on observation and interview, the manager failed to ensure that medications were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who had potential access to medications. Findings include: 1. The Compliance Officer observed a medication cabinet in the facility's kitchen which was unlocked. The Compliance Officer had access to R1's and R2's medications including: - Fluoxetine 40mg - Rosuvastatin 20mg - Trazodone 50mg - Tramadol 50mg - Mirtazapine 15mg - Senna 8.6mg - Risperidone .25mg 2. The Compliance Officer also observed an open box marked "caregivers medications" in the same cabinet. The Compliance Officer had access to the following medications: - Ibuprofen 600mg - Tylenol 325mg - Trazodone 100mg 3. In an interview, E1 confirmed that the following medications were in an unlocked cabinet in the facility's kitchen: - Fluoxetine 40mg - Rosuvastatin 20mg - Trazodone 50mg - Tramadol 50mg - Mirtazapine 15mg - Senna 8.6mg - Risperidone .25mg - Ibuprofen 600mg - Tylenol 325mg - Trazodone 100mg

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. The Compliance Officer observed a bottle of Clorox Clinging Bleach Gel in an unlocked cabinet in R2's bathroom. 2. In an interview, E1 confirmed that there was a bottle of Clorox Clinging Bleach Gel in an unlocked cabinet in R2's bathroom.